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Kingella kingae septic arthritis in an eight-year-old child
Consider perhaps the “group approach.” If the system can‘t separate two species cleanly, then report it as the “haenw!\.ifcrtshominis group, ” or the “epidermidi~hominis group.” When the isolate is clearly S. epidermidis (Excellent Identi-fication-High Confidence), then designate the species as such. We would then be in the ballpark as to what it isn’t. Otherwise, it should be reported as “CNS - not otherwise identified,” or “no species determined,” until such time as technology or the “species reduction” police catches up with Kloos and Schleifer. A stop-gap alternative, when it is appropriate to do so! would be the Stevens-Jones plate (trehalosemannitol-phosphatase agar) which could differentiate .S. epidemzidis from other CNS (10). If one placed a novobiocin disk on that plate, then S. saprophyticus could also be delineated (10). If the greatest majority of clinical11 significant blood and tissue isolates of CNS are S. epiderntidis, and for urines that species is less critical than S. saprophyticus, then one plate with a novabiocin disk would be sufficient.
Whatcvttr system is Iused to determine the species of CN,S, it should be used only in specific circumstances, e.g., establish epidemiologic trends, confirm treiltment failures? or establish the cause o:‘ specific infection (in consultation with clmicianr). Thcrc is no need to routinely identify CNS to species level, regardless of whc said what in the past. ‘Thus cndeth my “act of contrition” and “my penance,” whi#:h was to write this piece irk the space allotted and to do 100 tracheal aspirate Gam stains for specimen e:‘ficacy and acceptance.
Fitzgerald, R.H. et al. 1977. Deep wound sepsis following total k.ip arthroplasty. J. Bone Jl)int Surg. 591~847-855. Karchmel-, A.W. et al 1983. .S~LI~II$Ococc~~sq~idermidis prosthetic valve endocardltis: microbiological and clinical observations as guides to therapy. Ann. Intern. Med. 98:447-455. Lowry. F D. and S.M. Hammer. 1983. Srrgk> lo
mortality and hospital stay. Ann. Intern. Med. 110:9-16. 5. Dunne. W.%I., and T.R. Franson. 1986. Coagukc-negative staphylococci: the Rodney Dangerfield of pathogens. Clin. Microbial. Newsltr. 8(6):37-4:. 6. Koontr. 1-P.. and M.A. Pialler 1989. Coagulaac-negative staphylocck: why and when to do what. Clin. Mlcrobiol. Newsltr I I(1 b): 125-l 28. 7. Pfallcr. M.A., and L.A. Herwaldt. 1988. Laboratory. clinical and epidemiological aspects !)I’ cuagulase-negati\,e staphylococci. CIIII. Microbial. Rev. 1:281-299. 8. Kloos. WE., and K.H. Schkeit’er. 1975. Simpliiled scheme for routlnc identificatlon ot‘ human Srrcph~k1c~~c~~,4s species. J. Clin. Microbial. I :82-8X. 9. Per]. TM. ct al. 1994. Comparison of identificalton systems for Stcq~hyioCO~CIUc~yhhmidis and other t,oagulasenegative S!~1plz$ococcus species. Diag. Microhli.)l. Infect. Dis. 18: 152.155. lO.Stevens. D.L.. and C. Jones. 1984. Use of trehalose-mannitol-phosphatase agal to differentiate Stuphy/ococcu.r epidermidi. and Staphy/ococc~rs sczox~phyficus from other coagulase-negative staphylococci. J. C.‘lm Microbial. 20:9’W980.
Case Report
Kingella kingae Septic Arthritis in an Eight-Year-Old Juliette Holland, B.Sc., M.B., B.S., M.Sc., FRCPA Registrac Department of Microbiolog!, and Infectious Diseases Women i and Children’s Hospital Adelaide, Australia SA 5006 Kingellu kingae is a non-motile, gram-negative bacillus belonging to the Pdmily Neisseriuceae. It is a commensal of the upper respiratory tract and is a rare cause of invasive disease including endocarditis, pneumonia, bacteremia, and skeletal infections. Childhood cases of K. kingae septic arthritis have been described previously, but almost exclusively in children less than five years old and usually less than two years old. This case is of note in that it occurred in an eight-year-old child, organisms were seen on the Gram stain of the synocial fluid, and the organism grew on routine
solid media without the need for enrichment in systems such as the BACTEC blood culture system.
Case Report An eight -year-old, previously healthy girl presented with a 36-h history of increasing pain in her left leg. She had been training for a “wali
Child
A complete hlood count OJI admission showed a lrukocytosis of 22:0OO/mm’ (82% neutrophils) and an erythrocyte sedimentation rate was 55 mm/h. A plailn radiograph of her hips was normal, but an ultrasound of the left hip revealed a large effusion. The fluid from the joint was drained surgically, and she was commenced on intravenous flucloxacillin and cef‘otaxime empiricaily. She remained i’ehrlle for an additional 24 h. but by da> three her fever had :sertled and the flucloxacillin was discontinued. On day four she began to ambulate, the cefotaximc was ceased, and shi: commenced or.;11amoxicillin. Arno:ticillin was continued for a total of 4 weeks, and she made an unremarkable recovery with no re\idual joint damage. The ~y~lov~al fluid contained many neutrophilx. and scanty, medium sized.
square ended gram-negative rods arranged in pairs were seen on microscopy of a centrifuged sediment. After 24 h incubation (37°C in 5%, CO!I. a light growth of bacterial colonies wa\ observed on 5% horse-blood and chocolate agar, but not on subculture tc\ MacConkey agar. Colonies were small (less than 0.5 mm), hemolytic, oxidas~.. positive, and catalase-negative. An odder of hypochlorite and pitting of the agar reminiscent of Eikettellu corrodens was observed. However, biochemical analysis performed using the NH1 card (Vitek Systems, Hazelwood, MO) Identified the organism as K. kirgae with a probability of 99% (bionumber 664200). Disk diffusion susceptibility tests were performed. The organism failed to grow on Mueller-Hinton agar, however growth was possible on Mueller-Hinton .agar supplemented with horse blood giving large zones of inhibition to penicillin, ampicillin, amoxicillin plus clavulanic acid (Augmentin), co-trimoxazole, and cefotaxime, and considered susceptible using NCCLS criteria for Neisswiaceue. Minimum inhibitory concentrations to penicillin, ampicillin, and cefotaxime were determined using E-test strips (AB Biodisk, Solna, Sweden) and gave MICs of 0.012, 0.023, and 0.061( respectively.
Comment K. kingae is a rare but increasingly recognized cause of invasive infections with skeletal infections being the most common manifestation (1). A respiratory portal of entry for the organism has been postulated and, as with this case, symptoms of upper respiratory tract infection have been noted commonly. Concomitant stomatitis has also been a feature, although the child in this report was said to have bitten her lip subsequent to the onset of illness. The organism can be frequently isolated from the upper respiratory tract of healthy infants and children, particularly when a selective vancomycin-containing
Clmcal
Microbiology
Newsletter
20:9,1998
blood ag,tr medium is used (2). Yagupsky and coll~~~gues (3) identified the organisin 1113:;s of tonsrllar swabs. but not from nasupharyngeal cultures of a cohort of inlant II ape 6 mo to 4 yr. altending a day-care i:en(cr. These investigators also n,tcj a tiecreased prevalence of carriage II-I chlldr.tn older rhan 4 yr and youngci than 0 RIO ih% of well surgical patients and O(i I)1’X I infant:, attending ;I vaccin;mon clinic. respeclikely’~. The age 01 hiphckt c,arriage rate!* parallels the age distrrhution of puhlished cases of K. kirt,qtrcr intectrons: ;t review crf 42 pediatric infc,ctions presenting to an Israeli hospital over an 8 ye:ar period reported that YO’%:of cases c)ccurred in children 6 1n11to ? yr of age with the remaining children being under 40 mo ( 1I. Similarly. of 49 pediatric patients with septic arthritis reported to date, 47 (96%) were less thari 5 yr old. Adult cases have been described but are rare (1,4). This current casls is unusual In thar the child was 8 yi old. Isolation of K. kingae may prove difficult In this report, the Gram stain of’ the sl novial fluid was positive and K. kitgot> was isolated on direct culture. In the e,,perience of other investigators, however. this is uncommon. For example. in one study attempts to isolate the organisl;l from syncjvial fluid succeeded in only :! of 25 cases which subsequently yielded growth after inoculation of the specimen into aerobic BACTEC blood culture bottles (5). Cultt~ral and biochemical features that distmguish K. kingae from related organisms are as follows: Kingefla species ;tre plump, gram-negative bacilli that sometimes occur in pairs. Growth occurs on blood and chocolate agars, wherca:, no growth is seen on selective enteric Inedia; organisms arc oxidasepositive and, unlike Neisseriu and Morum’lo species, catalaae-negative. Unlike ::arz~iohu(~rc~rir*ttI hominis, Eikcwelta corrodetrs. Kingella denitrificum. and Sutortella itldologerles. most
strains $#howslight beta-hcemolysis on
0 1998 Elsev~~ Science Inc
blood agar K. kingw is indl)lc-negati1.e ;md produces acid from glu;:ose and maltose I‘hese biochetnicai rcuctions are included in the Vitek NHI card which \C;LSused to help iclcntit‘y the isolate
111this report.
Slmilx
to other
Ib.‘71,horse blood supplemenIatlon I !1 hlucller-Hinton agar was IICLcss~y I’oI, .u~timicrohial ,usceptibillt!, Icstlng Kirrgc>lltr \pecieb$ ;irc highI;; ~~uxq7~lt~l~: 10 a wide ranges oi‘antirnicrohial agents with the s:iccption of trmrcthoprirn (7) and cat! be treatet! with ht:&l,lctam agents wil h usually a f:lvot :1tile outcome (8 ). report>.
P., and R. Dagan. 1997.
\rapupshy.
Kirryc4h kingue: an emergmg cause ol invavlve infections in young children. C’lirl Intect. Dis. 24:860-866. Yagup~ky. P. et al. 1995. Evaluation of a noccl vancomycin-containlnp medium I’or the primary lsolatlon ol’ Kingellnz kinpc~~ from upper resplrat’ory tract specimen>. J Clin. Microbial. Jl: 1426-1417. P., R. Dagan. and M. W:rircs. ls)W Respiratory carriapc ot’Kinge/iu
\iagupsky,
kim:oe among healthy chil~3ren. Pediatr. Infect. DIS. J. 14:673-67X. Franklin,
G.W.. andA.S.
Shafi. 198.:.
Spc~~ntaneousseptic arthrltrs due to ki~~g;cl/ci kirzgae. Clin. Mlcrobiol. Newsletr. 5:53-54. Yapupsky. P et al. 1993. High prevalence OKK~~ptfl/u kir~gar in joint fluid from children with septic arthritis revealed by thr HACTEC blood culture system J (-111~ Wicrohiol. 30:) 2711-1281.
Raytnond, J. et al. 15%. fbolation of two stram of Kingella kingcw associated with s.eptic arthritis. J. (‘Iin. Microtxc~i. 24:1100-1101. Truhrrg. K.T.. H. Schonheyder, and V.F. 7’hvmsen. 194. In vim) activity of ‘Mu-lactam and other antimicrobial agelIt\ against Kirqydlo ki~r,que.J. Anr~nncrob.
Chemother.
33:035-640.
‘x’agupshy. P. et al. 1995. E:pidemiologq. etiology, and clinical features of septic arillrltis in children younger than 24 Inorltl~s Arch. Pediatr. Ad~~lesc. Mctl. 14r1 3.3’7.540.
0 I96-4399/96/$0.(!0
+ I Y 00
81
Whatcvttr system is Iused to determine the species of CN,S, it should be used only in specific circumstances, e.g., establish epidemiologic trends, confirm treiltment failures? or establish the cause o:‘ specific infection (in consultation with clmicianr). Thcrc is no need to routinely identify CNS to species level, regardless of whc said what in the past. ‘Thus cndeth my “act of contrition” and “my penance,” whi#:h was to write this piece irk the space allotted and to do 100 tracheal aspirate Gam stains for specimen e:‘ficacy and acceptance.
Fitzgerald, R.H. et al. 1977. Deep wound sepsis following total k.ip arthroplasty. J. Bone Jl)int Surg. 591~847-855. Karchmel-, A.W. et al 1983. .S~LI~II$Ococc~~sq~idermidis prosthetic valve endocardltis: microbiological and clinical observations as guides to therapy. Ann. Intern. Med. 98:447-455. Lowry. F D. and S.M. Hammer. 1983. Srrgk> lo
mortality and hospital stay. Ann. Intern. Med. 110:9-16. 5. Dunne. W.%I., and T.R. Franson. 1986. Coagukc-negative staphylococci: the Rodney Dangerfield of pathogens. Clin. Microbial. Newsltr. 8(6):37-4:. 6. Koontr. 1-P.. and M.A. Pialler 1989. Coagulaac-negative staphylocck: why and when to do what. Clin. Mlcrobiol. Newsltr I I(1 b): 125-l 28. 7. Pfallcr. M.A., and L.A. Herwaldt. 1988. Laboratory. clinical and epidemiological aspects !)I’ cuagulase-negati\,e staphylococci. CIIII. Microbial. Rev. 1:281-299. 8. Kloos. WE., and K.H. Schkeit’er. 1975. Simpliiled scheme for routlnc identificatlon ot‘ human Srrcph~k1c~~c~~,4s species. J. Clin. Microbial. I :82-8X. 9. Per]. TM. ct al. 1994. Comparison of identificalton systems for Stcq~hyioCO~CIUc~yhhmidis and other t,oagulasenegative S!~1plz$ococcus species. Diag. Microhli.)l. Infect. Dis. 18: 152.155. lO.Stevens. D.L.. and C. Jones. 1984. Use of trehalose-mannitol-phosphatase agal to differentiate Stuphy/ococcu.r epidermidi. and Staphy/ococc~rs sczox~phyficus from other coagulase-negative staphylococci. J. C.‘lm Microbial. 20:9’W980.
Case Report
Kingella kingae Septic Arthritis in an Eight-Year-Old Juliette Holland, B.Sc., M.B., B.S., M.Sc., FRCPA Registrac Department of Microbiolog!, and Infectious Diseases Women i and Children’s Hospital Adelaide, Australia SA 5006 Kingellu kingae is a non-motile, gram-negative bacillus belonging to the Pdmily Neisseriuceae. It is a commensal of the upper respiratory tract and is a rare cause of invasive disease including endocarditis, pneumonia, bacteremia, and skeletal infections. Childhood cases of K. kingae septic arthritis have been described previously, but almost exclusively in children less than five years old and usually less than two years old. This case is of note in that it occurred in an eight-year-old child, organisms were seen on the Gram stain of the synocial fluid, and the organism grew on routine
solid media without the need for enrichment in systems such as the BACTEC blood culture system.
Case Report An eight -year-old, previously healthy girl presented with a 36-h history of increasing pain in her left leg. She had been training for a “wali
Child
A complete hlood count OJI admission showed a lrukocytosis of 22:0OO/mm’ (82% neutrophils) and an erythrocyte sedimentation rate was 55 mm/h. A plailn radiograph of her hips was normal, but an ultrasound of the left hip revealed a large effusion. The fluid from the joint was drained surgically, and she was commenced on intravenous flucloxacillin and cef‘otaxime empiricaily. She remained i’ehrlle for an additional 24 h. but by da> three her fever had :sertled and the flucloxacillin was discontinued. On day four she began to ambulate, the cefotaximc was ceased, and shi: commenced or.;11amoxicillin. Arno:ticillin was continued for a total of 4 weeks, and she made an unremarkable recovery with no re\idual joint damage. The ~y~lov~al fluid contained many neutrophilx. and scanty, medium sized.
square ended gram-negative rods arranged in pairs were seen on microscopy of a centrifuged sediment. After 24 h incubation (37°C in 5%, CO!I. a light growth of bacterial colonies wa\ observed on 5% horse-blood and chocolate agar, but not on subculture tc\ MacConkey agar. Colonies were small (less than 0.5 mm), hemolytic, oxidas~.. positive, and catalase-negative. An odder of hypochlorite and pitting of the agar reminiscent of Eikettellu corrodens was observed. However, biochemical analysis performed using the NH1 card (Vitek Systems, Hazelwood, MO) Identified the organism as K. kirgae with a probability of 99% (bionumber 664200). Disk diffusion susceptibility tests were performed. The organism failed to grow on Mueller-Hinton agar, however growth was possible on Mueller-Hinton .agar supplemented with horse blood giving large zones of inhibition to penicillin, ampicillin, amoxicillin plus clavulanic acid (Augmentin), co-trimoxazole, and cefotaxime, and considered susceptible using NCCLS criteria for Neisswiaceue. Minimum inhibitory concentrations to penicillin, ampicillin, and cefotaxime were determined using E-test strips (AB Biodisk, Solna, Sweden) and gave MICs of 0.012, 0.023, and 0.061( respectively.
Comment K. kingae is a rare but increasingly recognized cause of invasive infections with skeletal infections being the most common manifestation (1). A respiratory portal of entry for the organism has been postulated and, as with this case, symptoms of upper respiratory tract infection have been noted commonly. Concomitant stomatitis has also been a feature, although the child in this report was said to have bitten her lip subsequent to the onset of illness. The organism can be frequently isolated from the upper respiratory tract of healthy infants and children, particularly when a selective vancomycin-containing
Clmcal
Microbiology
Newsletter
20:9,1998
blood ag,tr medium is used (2). Yagupsky and coll~~~gues (3) identified the organisin 1113:;s of tonsrllar swabs. but not from nasupharyngeal cultures of a cohort of inlant II ape 6 mo to 4 yr. altending a day-care i:en(cr. These investigators also n,tcj a tiecreased prevalence of carriage II-I chlldr.tn older rhan 4 yr and youngci than 0 RIO ih% of well surgical patients and O(i I)1’X I infant:, attending ;I vaccin;mon clinic. respeclikely’~. The age 01 hiphckt c,arriage rate!* parallels the age distrrhution of puhlished cases of K. kirt,qtrcr intectrons: ;t review crf 42 pediatric infc,ctions presenting to an Israeli hospital over an 8 ye:ar period reported that YO’%:of cases c)ccurred in children 6 1n11to ? yr of age with the remaining children being under 40 mo ( 1I. Similarly. of 49 pediatric patients with septic arthritis reported to date, 47 (96%) were less thari 5 yr old. Adult cases have been described but are rare (1,4). This current casls is unusual In thar the child was 8 yi old. Isolation of K. kingae may prove difficult In this report, the Gram stain of’ the sl novial fluid was positive and K. kitgot> was isolated on direct culture. In the e,,perience of other investigators, however. this is uncommon. For example. in one study attempts to isolate the organisl;l from syncjvial fluid succeeded in only :! of 25 cases which subsequently yielded growth after inoculation of the specimen into aerobic BACTEC blood culture bottles (5). Cultt~ral and biochemical features that distmguish K. kingae from related organisms are as follows: Kingefla species ;tre plump, gram-negative bacilli that sometimes occur in pairs. Growth occurs on blood and chocolate agars, wherca:, no growth is seen on selective enteric Inedia; organisms arc oxidasepositive and, unlike Neisseriu and Morum’lo species, catalaae-negative. Unlike ::arz~iohu(~rc~rir*ttI hominis, Eikcwelta corrodetrs. Kingella denitrificum. and Sutortella itldologerles. most
strains $#howslight beta-hcemolysis on
0 1998 Elsev~~ Science Inc
blood agar K. kingw is indl)lc-negati1.e ;md produces acid from glu;:ose and maltose I‘hese biochetnicai rcuctions are included in the Vitek NHI card which \C;LSused to help iclcntit‘y the isolate
111this report.
Slmilx
to other
Ib.‘71,horse blood supplemenIatlon I !1 hlucller-Hinton agar was IICLcss~y I’oI, .u~timicrohial ,usceptibillt!, Icstlng Kirrgc>lltr \pecieb$ ;irc highI;; ~~uxq7~lt~l~: 10 a wide ranges oi‘antirnicrohial agents with the s:iccption of trmrcthoprirn (7) and cat! be treatet! with ht:&l,lctam agents wil h usually a f:lvot :1tile outcome (8 ). report>.
P., and R. Dagan. 1997.
\rapupshy.
Kirryc4h kingue: an emergmg cause ol invavlve infections in young children. C’lirl Intect. Dis. 24:860-866. Yagup~ky. P. et al. 1995. Evaluation of a noccl vancomycin-containlnp medium I’or the primary lsolatlon ol’ Kingellnz kinpc~~ from upper resplrat’ory tract specimen>. J Clin. Microbial. Jl: 1426-1417. P., R. Dagan. and M. W:rircs. ls)W Respiratory carriapc ot’Kinge/iu
\iagupsky,
kim:oe among healthy chil~3ren. Pediatr. Infect. DIS. J. 14:673-67X. Franklin,
G.W.. andA.S.
Shafi. 198.:.
Spc~~ntaneousseptic arthrltrs due to ki~~g;cl/ci kirzgae. Clin. Mlcrobiol. Newsletr. 5:53-54. Yapupsky. P et al. 1993. High prevalence OKK~~ptfl/u kir~gar in joint fluid from children with septic arthritis revealed by thr HACTEC blood culture system J (-111~ Wicrohiol. 30:) 2711-1281.
Raytnond, J. et al. 15%. fbolation of two stram of Kingella kingcw associated with s.eptic arthritis. J. (‘Iin. Microtxc~i. 24:1100-1101. Truhrrg. K.T.. H. Schonheyder, and V.F. 7’hvmsen. 194. In vim) activity of ‘Mu-lactam and other antimicrobial agelIt\ against Kirqydlo ki~r,que.J. Anr~nncrob.
Chemother.
33:035-640.
‘x’agupshy. P. et al. 1995. E:pidemiologq. etiology, and clinical features of septic arillrltis in children younger than 24 Inorltl~s Arch. Pediatr. Ad~~lesc. Mctl. 14r1 3.3’7.540.
0 I96-4399/96/$0.(!0
+ I Y 00
81